Journal of Substance Abuse Treatment 45 (2013) 381–387

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Journal of Substance Abuse Treatment

The effect of recovery coaches for substance-involved mothers in child welfare: Impact on juvenile delinquency Jonah A. Douglas-Siegel, M.S.W. a,⁎, Joseph P. Ryan, Ph.D b a b

University of Michigan, School of Social Work and Department of Sociology, 1080 South University Ave, Ann Arbor, MI 48109, USA University of Michigan, School of Social Work, 1080 South University Ave, Ann Arbor, MI 48109, USA

a r t i c l e

i n f o

Article history: Received 28 October 2012 Received in revised form 20 May 2013 Accepted 30 May 2013 Keywords: Substance abuse/dependence Young adults Juvenile delinquency Intervention Foster care

a b s t r a c t Despite the documented relationship between parental substance abuse and youth delinquency, the effects of parental interventions on delinquency outcomes are unknown. Such interventions are particularly vital for families in the child welfare system who are at heightened risk for both parental substance involvement and youth delinquency. The current study tested the impact of intensive case management in the form of a recovery coach for substance-involved mothers on youth delinquency outcomes among a randomized sample of 453 families involved in a Title IV-E experimental waiver demonstration in Cook County, Illinois. In comparison to control group participants, families enrolled in the Alcohol and Other Drug Abuse (AODA) waiver demonstration experienced a lower rate of juvenile arrest, net of factors such as demographic characteristics, primary drug of choice, and time spent in substitute care. Findings support efforts to curb delinquency among child-welfare involved youth by providing recovery coaches to their substance abusing or dependent parents. © 2013 Elsevier Inc. All rights reserved.

1. Introduction Children that live with substance abusing or dependent parents are at increased risk for delinquency-related behaviors including aggression, property destruction, truancy, conduct disorder, oppositional defiant disorder, and criminality. These findings are well documented throughout the empirical literature (e.g., Barnow, Schuckit, Smith, Preuss, & Danko, 2002; Carbonneau, Tremblay, Vitaro, Dobkin, Saucier, & Pihl, 1998; Gabel & Shindledecker, 1993; Grekin, Brennan, & Hammen, 2005; Sher, 1997). Yet surprisingly there exists little research on whether interventions for substance-involved parents can improve child delinquency outcomes. With more than six million children living with at least one parent who abuses or is dependent on alcohol or an illicit drug (Office of Applied Studies, 2002), intervening with substance-involved parents may be an effective means to reducing youth delinquency. The impact of parental recovery from substance involvement on children is of particular interest among families involved in the child welfare system (CWS), given the prevalence of both adult substance abuse and youth delinquency within this population. There is wide variation in estimates of families in the CWS that struggle with substance abuse, depending on issues such as how researchers define substance abuse/dependence and whether the studied populations include inhome versus out-of-home cases (Jones, 2005; Young, Boles, & Otero, ⁎ Corresponding author. University of Michigan, School of Social Work, 1080 South University Ave, Room 3704, Ann Arbor, MI 48109, USA. Tel.: + 1 734 883 8575; fax: + 1 734 763 6887. E-mail address: [email protected] (J.A. Douglas-Siegel). 0740-5472/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsat.2013.05.010

2007). Overall, researchers estimate that substance abuse contributes to maltreatment in 33 to 80% of cases handled by child welfare agencies (Semidei, Radel, & Nolan, 2001; U.S. Department of Health and Human Services, 1999; Young, Gardner, & Dennis, 1998). As compared with other children in the CWS, the children of substance abusing parents tend to be younger, victims of severe and chronic neglect, and from families at greater risk for problems such as housing insecurity, domestic violence, and residence in dangerous neighborhoods (Magura & Laudet, 1996; U.S. Department of Health and Human Services, 1999; VanDeMark et al., 2005; Young et al., 1998). They are also more likely to enter a substitute care setting, remain in the out-of-home placement for significantly longer periods, and experience recurrent incidents of maltreatment or home removal (Brook & McDonald, 2009; Fuller & Wells, 2003; Miller, Fisher, Fetrow, & Jordan, 2006; U.S. Department of Health and Human Services, 1999; Wolock & Magura, 1996). Children in this population have extremely high rates of fetal alcohol syndrome (FAS) and other fetal alcohol spectrum disorders (FASD), with children in the CWS 10 to 15 times more likely than the general population to be affected by FAS (Astley, Stachowiak, Clarren, & Clausen, 2002)1. 1 Children with fetal alcohol syndrome (FAS) and other fetal alcohol spectrum disorders (FASD) are typically characterized by minor facial anomalies, prenatal and postnatal growth retardation, and functional or structural central nervous system abnormalities. Individuals exposed prenatally to alcohol and other substances often experience lifelong struggles with the effects of FASD, which can include attention and impulsivity problems, mental retardation, memory deficits, antisocial syndrome, psychiatric problems, and high rates of substance dependence (Sokol, Delaney-Black, & Nordstrom, 2003; Wattendorf & Muenke, 2005). Children who suffer from FASD often require extremely high levels of care and a high proportion of these children end up in foster care (Brown, Sigvaldason, & Bednar, 2005; The National Child Traumatic Stress Network, 2002; Paley, 2011).

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The harmful effects of parental substance involvement experienced by children in the CWS are further compounded by high rates of youth delinquency, with between 9 and 29% of maltreated children engaged in delinquent activity (e.g., Smith & Thornberry, 1995; Stewart, Dennson, & Waterson, 2002; Widom, 2003; Zingraff, Leiter, Myers, & Johnsen, 1993). Research has linked maltreatment to an earlier onset of juvenile crime as well as an increased likelihood of recidivism and chronic reoffending (Widom, 1989, 2003). In comparison to children who are “less-maltreated,” youth considered “more-maltreated” on indices of the prevalence, severity, duration, and number of subtypes of maltreatment are more likely to commit violent crime, be arrested, and recidivate (Chang, Chen, & Brownson, 2003; Crooks, Scott, Wolfe, Chiodo, & Killip, 2007; Kelley, Thornberry, & Smith, 1997). Children in the CWS who suffer from FASD also have a disproportionately high risk of correctional involvement due to the effects of FASD on adaptive and social functioning (N. N. Brown, Connor, & Adler, 2012; Popova, Lange, Bekmuradov, Mihic, & Rehm, 2011) 2. Despite the prevalence of both parental substance abuse and youth delinquency among families involved in the CWS, no studies have focused on the effects of either parental substance abuse or recovery from substance abuse on youth behavior among this population. 1.1. The role of interventions for substance-involved parents on youth outcomes In the face of adverse familial conditions, children of substanceinvolved parents are at considerable risk for delinquency. Yet these risk factors may be substantially reduced pending parental alcohol or drug intervention programs. Although interventions for parental substance-involvement are common, only one study has examined the effects of parental participation on children's delinquency outcomes. The Focus on the Families project investigated whether the addition of intensive services to basic services for parents in methadone treatment prevented parental relapse and reduced the incidence of youth substance abuse and delinquency among 144 parents and their 178 children (Catalano, Gainey, Fleming, Haggerty, & Johnson, 1999). Through enrollment in a family skills training program, parents participated in 33 sessions of family training combined with 9 months of home-based case management. Children attended 12 of the sessions and were evaluated at 6 and 12 months on the following delinquency outcomes: use of cigarettes in the previous month, use of alcohol in the previous 6 months, use of marijuana in the previous month, and a combined delinquency scale (frequency of activities such as shoplifting, cheating, and property destruction). In all but one of the comparisons, the direction of effects for all delinquency measures favored the treatment group but was not significant. The treatment group did experience some moderate albeit nonsignificant improvements, including a reduction in prevalence of drinking at 12 months (12%), smoking cigarettes at 6 months (12%), and smoking marijuana at 6 months (7%). Other analyses of parental substance abuse interventions incorporated assessment scales that encompass children's internalizing and externalizing behavior, such as the Child Behavior Checklist (Dawe & Harnett, 2007; Kelley & Fals-Stewart, 2007; Kumpfer, 1998; Luthar & Suchman, 2000). Findings from these studies suggested that acting out behaviors improved following parental substance abuse intervention. Kelley and Fals-Stewart, for example, reported a positive relationship between parents' functioning following intervention for paternal alcoholism and children's measures of adjustment as rated by children, parents, and teachers, particularly for externalizing behaviors in preadolescent children. Similarly, a 14-week drug prevention program designed 2 FASD has been linked to difficulty processing information and making good decisions, and is associated with aggression, conduct disorders, violence, and other maladaptive behaviors (Brown et al., 2012).

for drug-dependent parents demonstrated that skills training for parents was associated with increased compliance and fewer acting-out behaviors in children aged 6–10 (Kumpfer, 1998). Finally, substance abusing parents at risk of child maltreatment who participated in a home-based treatment program showed substantial reductions in child behavior problems (Dawe & Harnett, 2007; however, see Luthar & Suchman, 2000, for a similar study with nonsignificant findings). 1.2. An integrated approach to parental substance involvement We sought to advance the knowledge base and contribute to the literature on parental interventions and youth delinquency outcomes. The current study tested the effectiveness of an integrated model for substance abusing or dependent mothers in the CWS on preventing juvenile delinquency. This integrated model emerged out of an existing service partnership between the Department of Alcoholism and Substance Abuse (DASA) and the Illinois Department of Children and Family Services (IDCFS), and represented a Title IV-E wavier demonstration in the State of Illinois. Title IV-E waivers permit states to by-pass federal regulations related to the financing of foster care services in order to develop and test innovative strategies for serving children and families. Waiver demonstrations are approved by the Children's Bureau (part of the U.S. Department of Health and Human Services), prefer random assignment, and require cost neutrality. The effectiveness of this integrated model has been demonstrated to increase the rate of service access and the likelihood of family reunification (Ryan & Huang, 2012). The current study focused on the effectiveness of this model with regard to preventing delinquency after children have been returned home from foster care. The integrated model in Illinois was achieved through intensive case management in the form of a recovery coach. Coaches are one part of a larger recovery-oriented model of care that considers addiction to be a chronic condition rather than an acute disorder and thus promotes a long-term, holistic approach to recovery (White, Boyle, & Loveland, 2002). Under this model, recovery coaches play a central role in sustaining recovery management by facilitating access to supportive services, addressing personal and family obstacles to recovery, and motivating clients to develop sober-based lifestyles (White, 2006; White et al., 2002). Empirical evidence supports the long-term treatment of addiction (e.g., see McLellan, Lewis, O'Brien, & Kleber, 2000; White et al., 2002) through team-based models of recovery (White, 2006; Young et al., 1998) that include the assignment of individual counselors to clients (McLellan & McKay, 1998). Parents involved in the CWS who are assigned to recovery coaches are more likely to engage in treatment and to access services more quickly (Ryan, Marsh, Testa, & Louderman, 2006; Ryan, Choi, Hong, Hernandez, & Larrison, 2008). 1.3. Study objectives To investigate the effectiveness of recovery coaches with regard to the likelihood of juvenile delinquency, this paper addresses the following research aim: among children in the CWS with substance abusing or dependent mothers, does parental assignment to the experimental group (i.e., recovery coach) decrease the risk of youth delinquency over time? We answer this question by analyzing a subset of families that were randomized to the Illinois Title IV-E waiver demonstration. We hypothesize that youth whose mothers work with recovery coaches will have lower rates of delinquency over time. We anticipate that the success of the recovery coach model in helping mothers cope with substance abuse issues and other formidable life challenges will, in turn, create familial environments with less discord and child maltreatment, increased

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communication and parent–child involvement, and ultimately, lower rates of juvenile offending.

2. Methods 2.1. Study design and participants Eligible families for the waiver demonstration included all foster care cases opened on or after April 28, 2000 in Chicago and suburban Cook County. To qualify for the project, parents in substance-involved families (defined as either substance abusing or dependent under DSM-IV guidelines) were referred to the Juvenile Court Assessment Program (JCAP) at the time of their temporary custody hearing or at any time within 180 days subsequent to the hearing. JCAP provides alcohol and drug assessments for adults 18 years and older. JCAP is located on site at the Juvenile Court Building in order to provide convenience and easy accessibility for parents who have lost custody of their children and who are in need of an assessment to determine if a referral to drug treatment is appropriate and necessary. The assessment and referrals for treatment are based on the criteria established by the American Society of Addiction Medicine, which specify the following four levels of care: outpatient, intensive outpatient and partial hospitalization, medically monitored inpatient (residential treatment), and medically managed intensive inpatient treatment (O'Toole et al., 2004). JCAP conducts approximately 1000 assessments within the court building each year. Of these 1000 referrals, approximately 61% resulted in referrals to treatment providers. Of the clients indicated for treatment, approximately 50% were eligible for the IV-E AODA project because they met the following eligibility requirements: (1) their case was within the jurisdiction of Cook County, Illinois, (2) temporary custody of their child(ren) had been granted to the Illinois Department of Children and Family Services (IDCFS), and (3) parents were assessed at JCAP within 180 days of the Temporary Custody Hearing. Eligible parents were randomly assigned to either the control group (services as usual) or the experimental group (services as usual plus the services of a recovery coach) 3. For our initial sample, we selected all women enrolled in the IV-E AODA Demonstration Waiver as of June 30, 2010. Because this study is focused on the relationship between interventions at the parental level and child outcomes, we further limited our sample to include only those children that were reunified with their biological mothers 4. We assumed that there were far fewer direct effects of parental interventions for youth that were never returned home. As of June 30, 2011, 1,010 children associated with the waiver demonstration were reunified with the biological mother. Reunification was defined as a child leaving a substitute care setting and returning to the biological family home. We also limited the sample to include only those youth that were realistically eligible for a delinquency petition in the juvenile court. We selected youth that were at least 12 years of age within the observation period for the juvenile arrest data. If families were comprised of multiple children above the age of 12, we randomly selected one child for that family to avoid problems with nesting and violating the assumption of independent observations. Of the final sample (N = 453), 136 (30%) were associated with the control group and 317 (70%) were associated with the experimental (recovery coach) group 5.

3 See Author citation (Ryan & Huang, 2012; Testa, Ryan, Hernandez, & Huang, 2009) for more details on selection strategy and sample. 4 Reunification rates were nearly identical for the experimental and control groups, with only a few more children returned home in the experimental group. 5 The distribution of families assigned to the control (30%) and experimental (70%) groups reflects the random assignment ratio of the larger study (which was not a one to one randomization) (Ryan & Huang, 2012; Testa, Ryan, Hernandez, & Huang, 2009).

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2.2. Intervention The integrated recovery coach model in Illinois attempted to resolve and address competing agendas by ensuring independence. Recovery coaches in Illinois were not employees of child welfare or Alcohol and Other Drug Abuse (AODA) treatment agencies. This independence helped ensure that recovery coaches' primary concern were the families they served. The recovery coach services were provided by an Illinois-based non-affiliated social service agency, Treatment Alternatives for Safe Communities (TASC), that offers behavioral health recovery management services. Coaches carried a caseload of approximately eight clients and were required to participate in IDCFS and DASA trainings that covered a variety of topics including addiction, relapse prevention, DSM IV and American Society of Addiction Medicine criteria, fundamentals of assessment, ethics, service hours, client tracking systems, service planning, case management and counseling. The primary goals for the recovery coaches were to assist mothers in addressing their AODA problems, help mothers move toward reunification as safely and quickly as possible, and facilitate information sharing between child welfare, AODA providers, and court systems. In an effort to engage and retain mothers in treatment and other services needed for recovery, coaches paired recovery coach strategies suggested by White and colleagues (2006; 2002) with additional case management services. Specifically, recovery coaches provided the following services: (a) identification and coordination of necessary community-based treatment services and clinical assessments, (b) identification of and advocacy for public assistance benefits, (c) outreach to families in their communities, (d) drug testing, (e) reporting to child welfare caseworkers, (f) reminders of court dates and attempts to contact parents who have dropped out of treatment, and (g) permanency assessments and recommendations regarding reunification. 2.3. Data The current study utilized multiple sources of administrative data. The JCAP data contained demographic information on both children and mothers collected at the time of referral into the program including but not limited to race, employment status, living situation, education, receipt of public aid, presence of co-occurring problems, current alcohol and drug use, and prior treatment history. The IDCFS data included caregiver demographics, records of substitute care placements, and records of child maltreatment from each child's birth through the end of the observation period. Data on substance abuse or dependence recovery were retrieved from the Treatment Record and Continuing Care System (TRACCS) and included surveys completed by child welfare workers, recovery coaches, and treatment providers. The Cook County court data included official juvenile arrests between January 1, 2000 and March 31, 2012. The child welfare and juvenile justice data did not share a common unique identifier and were thus merged using probabilistic software. 2.4. Measures Juvenile arrests were coded as a binary variable in which 1 indicated a juvenile arrest between January 1, 2000 and January 1, 2012, and 0 indicated no arrest. The model controlled for a number of important predictors associated with substance abuse and child welfare outcomes that we selected from the available demographic and caregiver information. We sought to create a parsimonious model and include predictors that were associated with juvenile arrests in the broader literature. We retained predictors in the final model if the removal of that predictor altered remaining estimates. Predictors included child race, sex, and age; maternal employment status, marital status, mental health issues, skills deficiencies, and

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primary substance used; number of children in home; family housing problems; and time in substitute care. Variables were measured at the time of random assignment. For the characteristics of children, age was measured continuously while race (1 = African American) and sex (1 = male) were dummy variables. The housing, employment, mental health, and parenting skills items were completed by the caseworker where a value of 0 indicated the absence of the issue/ condition and a value of 1 indicated the presence of a particular issue/condition. Marital status was a dummy variable where 1 = never married. The measure of primary substance, also recorded by the caseworker, identified the most common substance used by each participant. Time in substitute care was calculated as the total number of days in a substitute care setting (e.g. foster care, residential care). 2.5. Data analysis We displayed descriptive statistics and used chi-square analyses to investigate potential differences between the experimental and control groups. We used survival analysis (SPSS Cox Regression v.14) to examine the influence of individual variables on survival rates. This analytic technique is similar to logistic regression in that it enables one to calculate the odds of a particular event (juvenile arrest) occurring. However, survival analysis considers the differential impact between groups on the timing of this event (Land, McCall, & Parker, 1994). We were interested in the predictive value of the recovery coach model alone and in combination with other relevant predictors. Thus, we ran an unconditional model and a fully developed model. 3. Results 3.1. Baseline data In the larger waiver demonstration, the random assignment procedures were successful in that there were no differences between the experimental and control participants with regard to any mother or child characteristics. However, in the current study, we focused only on those families that achieved reunification. We compared the groups to better understand (and control for) differences that emerged. Table 1 displays descriptive data for each of the predictors. There was minor variation between groups for all of the predictors. However, housing issues was the only predictor that differed significantly between the experimental and control groups, with 65% of families in the experimental group and 72% of families in the control group struggling with housing. There were no significant

Mean values indicated in italics. ⁎ p b .05.

Experimental group

Control group

(n = 317) %

(n = 136) %

8.1 76 46

7.9 79 41

21 3.9 33 55 69 65⁎

22 4.2 28 52 73 72⁎

822 73

3.2. Survival analysis The results from the Cox regression are displayed in Table 2. The table includes the coefficient and standard error for each independent variable as well as the hazard ratio. A hazard ratio greater than 1 indicates a higher likelihood of a juvenile arrest over time. A hazard ratio less than 1 indicates a lower likelihood of a juvenile arrest. If 1 is subtracted from the hazard ratio and the remainder is multiplied by 100, the resultant is equal to the percentage change in the hazard of arrest. Of the 453 youth in our sample, 56 (12.4%) were associated with a juvenile arrest after JCAP. In addition to controlling for participation in the recovery coach group, the Cox regression model also included caregiver and youth characteristics. Net of other important predictors, youth whose mothers participated in the recovery coach intervention were significantly less likely to be associated with a subsequent juvenile arrest than youth whose mothers participated in the control group. When controlling for youth and family characteristics, 9% of youth in the experimental group experienced an arrest compared to 19% of youth in the control group. Specifically, the hazard of arrest decreased by 52% for youth whose mothers were working with recovery coaches. In an unadjusted model, the hazard of arrest similarly decreased by 51% for youth in the experimental group (β = − .72; **p b .01; SE = .27; Exp(β) = .49). In addition, we observed that four other predictors helped explain the likelihood of a juvenile arrest. Youth whose mothers self-identified as primarily alcohol users (as compared with cocaine and heroin users) were significantly less likely to get involved with the juvenile justice system. In contrast, older youth (at the time of temporary custody) and males were significantly more likely to experience a juvenile arrest following parental intervention. Adolescents whose mothers (identified by the caseworker) struggled with parenting skills were also more likely to have a subsequent juvenile arrest. 4. Discussion 4.1. Findings Although debate continues regarding the precise estimates of substance-involved caregivers in the CWS, there is generally Table 2 Cox regression: impact of recovery coaches on juvenile arrest rate (N = 453).

Table 1 Comparison of experimental and control groups (N = 453).

Child characteristics Age Race (African American) Sex (male) Family characteristics Employed parent Number of children in home Alcohol as primary substance Parental mental health issue Parenting skills deficits Housing problems Length of time in substitute care Parent never married

differences with regard to age at entry into JCAP, race, sex, maternal employment status, number of children in the home, primary substance of choice, maternal mental health, maternal skills deficits, marital status or length of time in substitute care.

1092 75

Independent variables Child characteristics Age Race (1 = African American) Sex (1 = male) Family characteristics Employed parent Two children in home Three plus children in home Alcohol as primary substance Parental mental health issue Parenting skills deficits Housing problems Length of time in substitute care Parent never married Recovery coach group (1 = yes) ⁎ p b .05. ⁎⁎ p b .01.

B

S.E.

Exp (B)

0.39⁎⁎ 0.35 0.80⁎⁎

0.05 0.4 0.29

1.48 1.42 2.23

−0.29 0.49 0.46 −0.81⁎⁎ 0.62 0.94⁎

0.35 0.67 0.61 0.38 0.35 0.46 0.4 0.01 0.31 0.29

0.74 1.64 1.58 0.44 0.79 2.56 0.57 1 0.79 0.48

−0.56 0.01 −0.24 −0.74⁎⁎

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agreement on at least four fronts. First, a high percentage of foster care cases are associated with chronic drug and alcohol abuse. Second, substance involvement compromises parenting practices and jeopardizes the healthy development of children. Third, parental substance abuse and dependence are associated with an increased risk of juvenile delinquency. Fourth, there is a need to develop, implement and rigorously evaluate interventions to address parental substance involvement and improve child well-being for child welfare systems. Safety and permanence remain the core focus of child welfare. Yet, as the foster care population ages and as the field recognizes that more than 24,000 adolescents are making the transition to adulthood (Courtney et al., 2007), it is critical that child welfare interventions focus on broad measures of child and family well-being. The current study investigated the effectiveness of the recovery coach model for mothers in decreasing the risk of juvenile delinquency in a sample of high-risk, substance-involved families. The findings indicate that 12.4% of youth enrolled in the Illinois AODA waiver demonstration were associated with at least one juvenile arrest subsequent to the temporary custody hearing. The findings also suggest that maternal participation with recovery coaches was helpful in reducing the risk of youth delinquency. Nineteen percent of the youth associated with the control group (i.e. services as usual) experienced at least one subsequent arrest as compared with only 9% of youth in the experimental (i.e. recovery coach) group, for whom the hazard of arrest decreased by 52%. This difference persisted even after controlling for other important factors such as child age, child race, child gender, maternal mental health problems, primary drug of choice and time spent in substitute care. These results echo prior findings suggesting that substance abuse treatment for parents has the potential to positively impact their children (Dawe & Harnett, 2007; M. L. Kelley & Fals-Stewart, 2007; Kumpfer, 1998). The current findings advance this knowledge base by (1) identifying the impact of interventions for maternal substance abuse or dependence directly on youth arrest rates, and (2) testing the efficacy of a specific case management program for substance-involved mothers in creating family environments in which children are less likely to engage in offending behavior. 4.2. Limitations It is instructive to take several aspects of our sample selection and data measurement into account when interpreting the analysis. First, many of the children in the sample were still relatively young at the end of the data collection period and had not reached the peak offending years (14–16), so it is reasonable to assume that our estimate of delinquency will increase with the inclusion of older children. In addition, by limiting our sample to youth who were officially reunified with their mothers, we were unable to estimate the effects of substance recovery on children who were not reunified but may have had continued contact with their families. However, we assumed that children who experienced reunification were exposed to the most direct effects of the recovery coach intervention. With regards to data measurement, we measured the effects of maternal participation with recovery coaches on youth delinquency. In future work, we hope to use a more specific measure of progress to extend our analysis to include the relationship between recovery and delinquency (see Andreas, O'Farrell, & Fals-Stewart, 2006; Kelley & Fals-Stewart, 2007 for examples of how parental progress in substance abuse treatment affects youth). Similarly, our assessment of the relationship between maternal case management by recovery coaches and subsequent youth delinquency was unable to fully identify the precise familial mechanisms through which engagement with recovery coaches reduces the risk of youth offending. Previous research on substance abuse, family functioning, and youth misbehavior suggests a number of family mechanisms by which parental

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substance abuse may translate into youth externalizing behavioral problems and, as such, may be critical targets for parental intervention. These may include chronic family stress, hostile communication and family conflict, marital discord, low levels of family cohesion, and impaired parental problem-solving (Farrington & Welsh, 2003; Grekin et al., 2005; Jacob & Seilhamer, 1987; Sher, 1991; Smith & Stern, 1997; West & Prinz, 1987) 6. As we are unable to measure these mechanisms directly, we can confidently say that the risk of delinquency can be significantly reduced with the use of a recovery coach, but we can only speculate about which aspects of the recovery coach model were most successful. 4.3. Implications and future research The findings of this study point to a number of important clinical and policy implications while also building a framework for future research on the relationship between recovery from maternal substance abuse and juvenile offending. First, the positive effects of the recovery coach model on juvenile delinquency for families involved in the CWS suggest the need for continued development and evaluation of substance abuse interventions. This study demonstrated that the impact of interventions extends beyond parents and can contribute to reductions in juvenile crime. Researchers and clinicians should further explore how the recovery coach model can contribute to parental and youth success alike. Future research and program design should also investigate the findings that all families may not be equally responsive to participation in case management. Echoing prior research on age differences in the effects of treatment for parental substance abuse or dependence on children's overall adjustment (M. L. Kelley & FalsStewart, 2007), we found that younger children were less likely to experience an arrest following intervention. Older children who have been exposed to substance abuse for longer periods of time may require more substantial forms of intervention. Emerging research should identify the aspects of the intervention that are particularly useful for younger children while designing more intensive intervention programs for families with older children. Our analysis also indicated that youth whose mothers struggled with parenting skills were more likely to have a subsequent juvenile arrest. This is an important first step toward understanding the mechanisms by which parental interventions can improve youth behavior. Future research should aim to uncover how recovery from substance involvement shifts familial dynamics and which families are most receptive to change. Interventions can then be designed more effectively around the mechanisms that create reductions in delinquency. Finally, our analysis builds a framework for understanding the cost effectiveness of interventions for parental substance abuse and dependence. To date, the cost effectiveness of the AODA waiver has been limited to the calculation of foster care dollars. Future cost studies should include the long-term savings and behavioral economic benefits of decreased contact with the juvenile (and likely adult) justice system. In addition, decreased parental reliance on substances may also reduce future contact with the CWS.

6 Many of these mechanisms may result from the documented mental health needs of birth parents in the CWS. In addition to drug and alcohol abuse, this population of parents has been shown to have higher-than-average rates of serious mental health problems, domestic violence, and difficulty paying for basic needs (Burns et al., 2009; Libby, Orton, Barth, & Burns, 2007; NSCAW, 2005, 2007). Substance abusing women also have high rates of substance abuse in their families of origin and childhood experiences of sexual assault (Barth, 2001). Parents' own experiences with trauma can affect their capacity to form secure bonds with their children, compromise their decision-making abilities, and result in maladaptive coping strategies, among other symptoms (Appleyard & Osofsky, 2003; The National Child Traumatic Stress Network, 2011; VanDeMark et al., 2005).

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